| Document Date: 2010-03-22 14:20:49
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MedicalCondition visual disorder / Autism Headaches Blackouts Dizziness Fainting / pain / NO. No Yes Cancer Diabetes Down’s syndrome High blood pressure Seizure / allergies / serious diseases / blood pressure Vision disorder Heart disease Hearing disorder Allergies Nervous/emotional / Injury / Hernia (rupture) Diabetes Epilepsy / rheumatic fever / hearing disorder / H. Allergies / hepatitis / Enuresis / Illness / Bladder problem Fatigue / disorder VII / / MedicalTreatment speech therapy / / Organization Hopewell Valley Regional School District Division of Pupil Services / / Position undue tiredness Eating disorder Head / / Product F. What medication / / ProvinceOrState New Jersey / A. B. / /
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Hopewell Valley Regional School District Division of Pupil Services 425 South Main Street Pennington, NJ[removed]CONFIDENTIAL HEALTH HISTORY